On November 12, 2019, CMS issued a proposed rule that, if finalized, would have a sweeping impact on Medicaid programs across the country. The 222-page “Medicaid Fiscal Accountability Regulation” seeks to implement significant policy changes to some of the key financing sources for the non-federal share of Medicaid payments, including intergovernmental transfers and provider taxes. The rule would also impose additional requirements and restrictions on fee for service supplemental payments, in addition to new reporting and evaluation requirements. Eyman Associates continues to review the rule to fully assess the range of potential impacts on safety net providers.